>>Harvey - you state that your anesthesia department frowns upon the use
of SC in RSI in peditaric patients. What are the dangers, and in
particular, what is the true risk of these occurrences and how should
one balance the risk of these occurences aginst the risk of having a
child with a prolonged parlysing agent on board who cannot be intubated
because of a "difficult" airway situation?<<
Jeffrey, that is really the mother of all outstanding issues related to
RSI (if I am permitted to borrow a phrase from the Gulf war).
We had an extensive dicussion of these issues several years ago on this
same forum. Unfortunately, my last response at the time, which quantitated
the real risks, in the use of sux in chidren was not approved by the
moderator, presumably because I had failed to display sufficient deference
to some of the other pediatric 'experts' on the list.
As you know, sux is no longer approved for elective intubation of
children. However, the revised FDA labeling of sux does, indeed, sanction
its use in emergency situations. (Check thr PDR for info about this).
Even the authors of the reports of hyperkalemia after the use of sux in
children acknowedge its legitimate use in emergency situations (1).
The cases of hyperkalemia described in children after the use of sux have
generally occured after repeated doses of the drug or unrecognonized
pre-existing hyperkalemia, acidosis or myopathy. These have all been
described in an elective setting and, to my knowledge, have not occured in
In a series of over 5000 children only 3 developed the syndrome of
masseter muscle spasm (2).
So the risks seem to be reasonably small but they do add yet another
drawback to the use of sux in pediatric intubations.
Now every therapeutic modality has risks. So now we need to determine if
the short onset, short duration profile of sux is sufficiently
advantageous to overcome these rarely fatal drawbacks.
Now to my way of thinking, the short duration of sux is an overwhelming
advantage compared to nondeploarizing NMBs. In adults who have been
adaquately pre-oxyegentaed it is almost the case that they can withstand a
full 5 minutes of apnea until spontaneous repsirations resume should the
attempt at intubation fail. In children, admittedly, the tolerable limits
of apnea are less than this both because of a higher metabolic rate and
lower pulmonary reserve. Nevertheless, limiting the amount of time that
PPV needs to be adminstered in cases of failed intubation, is a great
advantage in limiting the complications of gastric distension and possible
I have heard it argued, incidentally, that this is not a good reason to
choose sux over a nondeporarizing NMB as 'even 5 minutes
of paralysis is too long without establishing an airway'. When faced,
however, with having to support ventilations for 5 mintues with sux as
compared to 25 or 30 minutes with the next shortest acting drug
(rocuronium) the fallacy of this reasoning becomes clear.
Here is a comment from a review of pediatric intubations published in the
Annals several years ago:
"The approach to the selection of a RSI paralytic agent should be based on
the emergency physician's determination of which drug will permit the
quickest, safest conditions for ETI in a particular child. Selection
should not be based on implications of a failed intubation." (3).
Once again, this is an idiotic statement that contradicts itself because
one of the main criteria in determining which drug is safest is in
deciding what options will still be available should the intubation fail.
What they are trying to say, here, is that the need for intubation still
exists. It is irrelavent whether the patient is paralyzed for a long
or a short period of time. But it confuses the need intubation with that
for active airway management which will include positioning, suction,
oxygen, nasal or oral airways and, if necessary PPV. It ignores the fact
that all of these modalities may be sucessful in maintaining oxygenation
and ventilation until the patient resumes spontaneous respirations or a
definitive airway is secured. This is clearly is much easier to accomplish
if the duration of paralysis is 5 minutes rather than 30 minutes.
So, in summary, I would say that sux, because of its short duration of
action, has a built in margin of safety. In adults its drawbacks are minimal in
most cases and, thus it continues to be the paralyitc of choice. In
chidren, the risk/benefit ratio is more ambiguous by virtue of rare but
fatal and often unpredictable side effects.
Pick your poison.
[Heart arrest in children after intravenous injection of succinylcholine
in the ENT operating room (see comments)]
HNO 1995 Nov;43(11):676-9
Acute rhabdomyolysis with hyperkalemia has been followed by ventricular
dysrhythmia, cardiac arrest and death after the administration of
succinylcholine to apparently healthy children who were subsequently found
to have undiagnosed skeletal muscle myopathies. Boys have mostly been
affected. Reports of anesthesia emergencies from the United States and
Germany have indicated that serious side effects of succinylcholine are
not as rare as previously thought. This disorder often presents as sudden
cardiac arrest within minutes after the administration of the drug. The
tragedy is that an apparently healthy child dies abruptly during what was
considered to be a relatively uncomplicated surgical procedure (most often
in ENT surgery). Due to the abrupt onset of rhabdomyolysis, routine
resuscitative measures are likely to be unsuccessful. Extraordinary
measures(including institution of extracorporeal circulation) and prolonged
efforts have resulted in successful resuscitation of some cases. Since
there are usually no signs or symptoms to alert the practitioner to
patients at risk, the use of succinylcholine in children should be
reserved for emergency intubations or instances in which immediate
securing of the airway is necessary.
Lazzell et. al. The incidence of masseter muscle rigidity after
succinylcholine in infants and children Can J Anaesth 1994
Gerardi et. al. Rapid-Sequence Intubation of the Pediatric Patient. Ann
Emer Med 1996;28:55-74
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